Steve Carstensen DDS University of the Pacific Alumni 2019 ...
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Putting Airway Therapy to Work in Your Practice
Steve Carstensen DDSDiplomate, American Board of Dental Sleep Medicine
Private Practice, Premier Sleep, Bellevue, WA Editor-in-Chief, Dental Sleep Practice Magazine
DisclosuresEditor of Dental Sleep Practice MagazineHave Lectured for Various Companies
Director of Sleep Education for Pankey Institute
Guest Lecturer at Spear Education, University of the Pacific and Louisiana State Dental School
Advisory Board, SleepArchiTx
You Want to Incorporate
Dental Sleep Medicine
Into Your Practice
It’s
Airway Therapy
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 1
Making it Happen in Your Practice Requires
Organization Disruption Rewards
Prepare Your TeamAware of Risk FactorsScreen Every PatientSeek a Diagnosis
“High perceived benefit is the first, and perhaps the most important, step
on the road to therapeutic acceptance and utilization”
Principles and Practices of Sleep Medicine, 5th ed.Chapter 142: Monitoring Techniques for Evaluating Suspected Sleep-
Disordered BreathingHirshkowitz and Kryger
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 2
Today is about Creating Action Plans
What are You Going to Do?Be Clear On the Benefit
What’s A Benefit?
Know Your Work
Know Yourself
Know Your Patient
Apply Your Knowledge
Active Listening Exercise
Team Learning“So that we can work well together,
what should I know about you?”
5 minutes - Questions - Switch
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 3
Prepare Your TeamEveryone TerminologyImportance
Reception: Phone Questions
Admin: Insurance and Finance
Chairside: Intake and Support
Hygiene: Screening and Health
Jim Pride DDS
“You may be smarter than me,
but you’re not smarter than me and my team”
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 4
Terminology
AHI RDI
ODI
REIHypopnea
TST
Supine
MAD HST PSGNon-Rapid Eye Movement (NREM) Sleep (aka: quiet sleep or synchronized sleep) neuronal quiescence
Rapid Eye Movement (REM) Sleep (aka: active sleep or desynchronized sleep)
generalized neuronal activity
Non-REM
REM
NonRem
REM
1
2
3
1
2
3
Sleep Architecture - Hypnograms
Apnea
Hypopnea
Apnea-Hypopnea Index
AHI = REI
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 5
Hypopnea Has Two Definitions
1A: when ALL criteria are met:1. 30% reduction in airflow on nasal pressure
transducer or PAP flow signal2. Event lasts > 10sec3. 3% O2 desaturations or arousal
1B: Hypopnea
3. 4% oxygen desaturation from baseline
Apnea
Hypopnea
Respiratory Disturbance Index
RDI
Arousal
Mild 5 - 15 episodes per hour
Moderate 15 - 30 episodes per hour
Severe 30+ episodes per hour
Apnea: Diagnostic CriteriaCan’t Breathe = Obstructive Sleep Apnea (OSA)
Won’t Breathe = Central Sleep Apnea (CSA)
Sleep Disordered Breathing
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 6
Events longer than 10 seconds count Importance
Depression45%
Stroke63%
HeartFailure76%
SevereObesity77%
Drug-ResistantHypertension
83%
CoronaryArteryDisease
57%
A-fib50%
Type2Diabetes72%
AtrialFibrillation
Depression
45%
Drug-ResistantHypertension
83%
CoronaryArteryDisease57%
50%Type2Diabetes72%
Chronic Managed Diseases
Airway Therapy Helps
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 7
Importance
What in Your Life is Worse Because of
Your Airway Problem?
How Will Your Life Improve When
This Problem is Gone?
Aware
Risk Factors
Health History
Know Your Patient
Risk Factors
Obesity
Excessive Daytime Sleepiness
Snoring
Functional Somatic Syndrome
Functional Somatic Syndrome
migraine headache/tension headache syndrome
irritable bowel syndrome (IBS) fibromyalgia
temporomandibular joint (TMJ) syndrome
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 8
Health History
Do You Snore?
Describe Your Sleep Quality
Ever Been Evaluated for Sleep?
Health History
Heart Trouble?
Diabetes Type 2?
Hypertension?
Systemic Inflammatory Disease?
Actions You Can Take
What do you want to add to your HH?
Create a Team Meeting Agenda for Introducing Airway Therapy
Decide How You Can Teach Terminology to Your Team
Highlight on Your HH Questions Pertaining to Sleep
Team Meeting
Leader: You are a New Patient
Ask everyone an airway-related question from your medical history
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 9
Screening and Diagnosis
Finding Sleepy PatientsIn Your Practice
New HH Questions
Screeners
ScreenersEpworth Sleepiness Scale
STOP-BANG
The Elbow Test
Epworth Sleepiness
Scale
In contrast to just feeling tired, how likely are you to doze off or fall asleep in the
following situations?
Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze 1 = Slight chance of dozing
2 = Moderate chance of dozing 3 = High chance of dozing
SITUATION
______ Sitting and reading
______ Watching Television
______ Sitting inactive in a public place (i.e. theater)
______ As a car passenger for an hour without a break
______ Lying down to rest in the afternoon
______ Sitting and talking to someone
______ Sitting quietly after lunch without alcohol
______ In a car, while stopping for a few minutes in traffic
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 10
STOP-BANG
Do you Snore or has anyone told you that you do?
Are you Tired during the day?
Anyone Observed you Gasping or Choking?
Do you have high blood Pressure or take meds for it?
BMI > 35?
Age > 50
Neck Size > 40cm
Gender M?
Screeners
ESS: 10 or more for sleepiness
STOP-Bang: 3 - 4 is high risk for OSA
The Elbow Test
Does your bed partner ever poke or elbow you:
because you are snoring?
because you have stopped breathing?
The Elbow TestSnoring? OR of AHI>5: 3.9
Stopped breathing? OR of AHI >5: 5.8
Sensitivity: 65% Specificity: 76%
Positive Predictive Value 90%
Chest. 2014 Mar 1;145(3):518-24. doi: 10.1378/chest.13-1046.
The utility of the elbow sign in the diagnosis of OSA.
Fenton ME, Heathcote K, Bryce R, Skomro R, Reid JK, Gjevre J, Cotton D.
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 11
Exercise
Pairs: Present a Screener
Practice: Verbal Skills
Part I Communication Fundamentals 1. Understanding Communication 2. Preparing for Patient Communication 3. Developing Cultural Competence Part II Interaction Skills 4. Enhancing Listening Skills 5. Improving Verbal Skills 6. Refining Nonverbal Communication Skills Part III Communication During the Appointment 7. Initiating and Interviewing 8. Interacting During and After Procedures 9. Presenting Treatment Plans Part IV Communication Challenges 10. Managing Life Span Challenges 11. Managing Hearing and Speaking Challenges 12. Managing Stigma Challenges
How to Get Your Patients Tested
HST
PSG
Board-Certified Sleep Physician
Primary Care Physician
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 12
What Equipment Do You Need? What Equipment Do You Need?
What About Imaging?
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 13
Actions You Can Take
Who will find the sleep physicians in your community?
How will you go about making a relationship?
Actions You Can Take
Will you use HST-remote?
Sleep docs ?
Your own HST?
Are you comfortable with HST? Know your Sleep Docs well?
Actions You Can Take
How would you like to implement ESS, STOP-Bang and Elbow Test?
What format? Who is going to create them?
Who is going to discuss with your patients?
How is follow-up going to happen?
Meeting Sleep Physicians
They already know dentists
How are You Different?
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 14
Airway Treatment Choices are Settled
Testing is where the debate lies?
Organizing Your Practice
Do you need a Specialized Software Package?
Dental vs. Medical Notes
Software Driven
No One Checks
Very SpecificDefined TermsTwo CodesAuditsSets Up Payment
GIGO
Thinking Dental, Acting MedicalDental MedicalProduction
Daily Goals
Code-Driven
Ongoing Revenue
Collection %
Encounters
Patient Count
E&M
Upfront Revenue
Global Assessment
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 15
Jim Pride DDS
“The Numbers will set you Free,
….but first, they’ll tick you off” How Many Visits?
1. Initial Consultation
2. Records
3. Delivery
4. First Follow-up
5. Efficacy
6. 6 month or Annual
How Many Visits
Do You Get Paid For?
1. Initial Consultation
2. Records
3. Delivery
4. First Follow-up
5. Efficacy
6. 6 month or Annual
1. Initial Consultation
2. Records
3. Delivery
4. First Follow-up
5. Efficacy
6. 6 month or Annual
Requesting MD notes
Sleep Studies
Benefit Checks
Pre-Authorizations
Lab Communications
MD Letters
Admin Time
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 16
S – What the Patient Reports
O – What you Find
A – What You Decide
P – What You Prescribe
H
PE
MDM
History
Physical Examination
Medical Decision Making
Team Exercise
Pass out an encounter note from an MD office visit
Everyone highlights terms they know and don’t know
The Medical Encounter
5 Steps Check-In – Intake – Exam – Sign-Off - Checkout
Check InInsurance Card
Verify Benefits
Online Resources
Check on Co-Pay and Deductible
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 17
The Physical ExamNot much more than what you do now
Add Airway Details
Physical Exam Checklist
Three vital signs
General appearance
Inspection of lips teeth and gums
Examination of oropharynx, oral mucosa
Examination of neck
Orientation x3
Inspection of conjunctiva and eyelids
Examination of gait and station
Inspection of skin and subcutaneous tissues
Assessment of range of motion
Description of patient’s judgment and insight
Assessment of nasal mucosa, septum, and turbinates
Action You Can Take
Create a Template, Form, or Page
Physical Exam and Medical Decision-Making
Chief Complaint
Two Codes: DiagnosisProcedure
G47.33 OSA, adult and pediatric
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 18
Procedure
Evaluation and Management
Durable Medical Equipment
Evaluation and Management
9920x 1 - 5 for New Patients
9921x 1 - 5 for Existing Patients
5 Levels
Level 1: no doctor
Level 2: doctor involved
Level 3: detailed
Evaluation and Management
Level 5: not possible for dentists
Level 4: very detailed documentation
Evaluation and Management
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 19
Resources for Coding
1995 / 1997 CMS Guidelines
Durable Medical Equipment
E0486
Sign -Off and Checkout
The Doctor must sign all notes
Collections, Future Appointments
Action Items
Create Your “Why”
Choose your Screening Plan
Involve Your Team
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 20
Action Items
Decide on Specialized vs. Existing Software
Involve Your Team - Create a Task Force
Action Items
Decide on Medical Billing or Cash Practice
Make It About the Patient
(There are billing services to help you)
Team Exercise
List Every Money Question
Practice Answers
Most Important Fact15%
85%
Only 15% of patients at risk are diagnosed
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 21
Each Year
820,000 PAP abandoned
110,000 claims for E0486
1,700,000 PAP sold
ADA.org/Meeting
Your Patients Need Your Help
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 22
Go Help Them.Steve Carstensen DDS
SeattleSleepEd@gmail.com
SeattleSleepEducation.com
University of the Pacific Alumni 2019Steve Carstensen DDS
SeattleSleepEducation.com
March 2, 2019 23
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